Efficiencies Result in Better Outcomes in Patients with Strokes

Despite two decades of efforts to initiate therapy of patients with acute ischemic strokes (AIS) quickly, less than one-third of patients presenting with AIS in the United States, were treated within the guideline-recommended door-to-needle (DTN) time with tissue plasminogen activator (tPA).  Fonarow et al¹ article in JAMA discusses strategies that were implemented in a consortium of hospitals in order to reduce DTN time to 60 minutes or less for the initiation of thrombolysis with tPA in patients with acute ischemic strokes.

The Stroke initiative made recommendations to 1030 participating hospitals that treated 71 169 patients with AIS with tPA (27 319 during the pre-intervention period and 43 850 during the post-intervention period).  The quality stroke initiative included pre-notification of hospitals by emergency medical services (EMS), fast performance and interpretation of brain CT scans, immediate initiation of treatment for eligible patients, rapid feedback on performance and public recognition of high-performing hospitals.

Median DTN time for tPA administration declined from 77 minutes during the pre-intervention period to 67 minutes during the post-intervention period (P < .001). The DTN times for tPA administration of 60 minutes or less increased from 26.5% of patients during the pre-intervention period to 41.3% during the post-intervention period (P < .001). The annual rate of improvement in DTN times of 60 minutes or less increased from 1.36% per year pre-intervention to 6.20% per year post-intervention (P < .001). In-hospital all-cause mortality improved significantly from the pre-intervention to the post-intervention period from 9.93% to 8.25%, respectively (P < .001), symptomatic intracranial hemorrhage within 36 hours decreased from 5.68% to 4.68% (P < .001), and discharge to home was more frequent from 37.6% to 42.7% (P < .001).

Prior studies² have established that thrombolysis with tPA is effective when administered early with the goal being to initiate treatment within 60 minutes or less from the time patients arrive in the hospital.  The authors report that their initiative was associated with improved timeliness of thrombolysis following acute ischemic stroke on a national scale, and that this improvement was associated with lower in-hospital mortality and intracranial hemorrhage, along with an increase in the percentage of patients discharged home.

1.  Fonarow G, Zhao X, Smith E, Saver J et al. Door-to-Needle Times for Tissue Plasminogen Activator Administration and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative; JAMA. 2014;311(16):1632-1640.    doi:10.1001/jama.2014.3203.

2.  Hacke W, Donnan G, Fieschi C, Kaste M et al, Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004 Mar 6; 363(9411): 768-74.